Rs&c letter no. 00-17 --the use of haldol in nursing homes

Texas Department of Human Services * Long Term Care/Policy
Marc Gold Section Manager Long Term Care-Policy State Office MC: W-519
SUBJECT: Regional Survey & Certification Letter #00-17
The attached RS&C Letter is being provided to you for information purposes and should be shared with all professional staff. • RS&C Letter No. 00-17 --The Use of Haldol in Nursing Homes; Call Dee Sandefur, Nurse Specialist, Professional Services, at (512) 438-2631. If you have any questions, please direct inquiries to the individuals or sections listed above. DEPARTMENT OF HEALTH & HUMAN SERVICES
Health Care Financing Administration
Division of Medicaid and State Operations, Region VI 1301 Young Street, Room 833 Dallas, Texas 75202 Phone (214) 767-6301 Fax (214) 767-0270 REGIONAL SURVEY AND CERTIFICATION LETTER NO: 00-17 The purpose of this memorandum is to provide clarifications about surveyor guidelines for unnecessary drug use in nursing homes. Recently, we have received concerns from Senators Grassley and Breaux stating our regulations and guidelines do not prevent a facility from using Haldol to stop a resident from screaming, yelling, or pacing. Antipsychotic drugs should never be used to treat residents who continuously scream, yell, or pace unless these behaviors are shown to be symptoms of specific conditions (e.g., delusions, delirium); and that the other provisions of 42 CFR 483.25(l)(1)&(2) are met. The symptoms of yelling and screaming, in and of themselves, do not justify use of an antipsychotic drug. The use of these drugs is only appropriate when medically necessary to treat validated conditions, such as delirium and delusions. Delusions are false beliefs (medical symptoms), which sometimes occur in elderly individuals with dementias. If they are frightened and disoriented, they may demonstrate conditions such as continuous yelling, screaming, and pacing. Sometimes the delusions can reflect minor fluctuations in a chronic condition and do not constitute a problem requiring drug treatment. Other times, delusions may interfere with an individual's capacity to function or to enjoy life. In these cases, the resident may benefit from the limited use of such drugs as Haldol. However, if the delusions are not harmful and do not impact negatively on the resident's quality of life, then antipsychotic drugs should not be used. Surveyors are trained to carefully look for the evidence of each sampled individual's reason for receiving medications. Delirium is an altered state of consciousness; that is, the person is not fully awake. Delirium can be caused by a physical illness that is not yet diagnosed, and can be life threatening when unrecognized and untreated. Sometimes, antipsychotic drug use may be acceptable for a limited time to stop a serious unwanted behavior while care givers diagnose and treat the underlying medical problem that may be causing the delirium and unwanted behavior. Current guidelines to surveyors regarding antipsychotic medications (located under quality of care) relate medical symptoms to acceptable conditions, and give surveyors further instructions regarding individual assessment of a given situation. Please notify all SNFs in your state of the clarification in this letter and forward a copy of your
notification to Wanda Eskue
. If you have any questions concerning this letter, please contact
Wanda Eskue at (214) 767-4428 or Ginny Tibbetts at (214) 767-4411.
Molly Crawshaw, Branch Chief Survey and Certification Operations Branch


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